Form Dlse 106 - Application For Special Minimum Wage License (Labor Code Section 1191)
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Return Application To:
State of California
DLSE Licensing
Department Of Industrial Relations
P.O. Box 420603
DIVISION OF LABOR STANDARDS ENFORCEMENT
San Francisco, CA 94142
APPLICATION FOR SPECIAL MINIMUM WAGE LICENSE
(Labor Code section 1191)
Application is hereby jointly made for a license to pay a special minimum wage to an individual under the provisions of Section 1191 of the Labor Code
and Section 6 of the applicable Industrial Welfare Commission Order. PLEASE CAREFULLY READ THE ACCOMPANYING GENERAL INFORMATION
AND INSTRUCTIONS (DLSE 117-A) PRIOR TO COMPLETING THIS APPLICATION.
1a. Certified by U.S. Department of Labor?
Establishment employing worker with a disability:
Yes
No
Name __________________________________________________________________________
1.
If Yes, Certificate No. ______________
Exp. Date :
(Provide a copy)
Street Address:
If No, on a separate page, provide an explanation
of reason for no certification
City: ___________________ County: ________________ State: ______ ZIP Code: _______
Mailing Address (If Different than Street Address):
1b. Certified by California Department of
Rehabilitation?
Yes
No
If yes, Vendor No.
City: ___________________ County: ________________ State: ______ ZIP Code: ______
Exp. Date :
(Provide evidence)
Contact Person/Telephone:
Certified by California Dept of Developmental
Services/Regional Center?
Yes
No
Type of Business__________________________________ IWC Order No.___________________
If yes, Vendor No.
Exp. Date :
(Provide evidence)
Federal Employer ID No. (FEIN): ________State Employer ID No. (SEIN): ________
Worker with a Disability:
If legally conserved, Parent/Legal Guardian:
2
Name ____________________________________________________
3. Name: _____________________________________________________
.
Street Address: ______________________________________________
Street Address: _______________________________________________
City: _________________ State: _____________ ZIP Code: _______
City: ___________________ State: ___________ ZIP Code: _______
Telephone: (______) _____________
4a. Certified by U.S. Department of Labor?
Referring Organization:
Yes
No
Name _________________________________________________________________________
4.
If Yes, Certificate No. ______________
Exp. Date :
(Provide a copy)
Street Address:
If No, on a separate page, provide an explanation
of reason for no certification)
City: ___________________ County: ________________ State: ______ ZIP Code: _______
Mailing Address (If Different than Street Address):
4b. Certified by California Department of
Rehabilitation?
Yes
No
If yes, Vendor No.
Exp. Date :
(Provide evidence)
City: ___________________ County: ________________ State: ______ ZIP Code: ______
Contact Person/Telephone:
Certified by California Dept of Developmental
Services/Regional Center?
Yes
No
Status:
Public
Private, For Profit
Private, Not For Profit
Other _______
If yes, Vendor No.
Exp. Date :
(Provide evidence
5. Applicable primary program:
6. Status of Establishment Listed in No. 1, above: (Check One):
Public (State or Local Government)
Private, For Profit
Private, Not For Profit
Other ______________
If you checked Public, STOP – you do not have to complete this application – See General Information and Instructions
7. This is an application for a:
New License
Renewal License
See General Information and Instructions (DLSE 117-A) for information required to be listed on separate sheet
Proposed wage rate: $___________ per _________________ (hour/day/week/month ) for ______________hours per day/ ___________ days per week
Plus ____________________________________________________ (specify meals, lodging, other items)
If renewal, wage rate paid during period covered by previous license:
If renewal, and wage rate is lower than previous license period, provide explanation and justification for lower wage rate. (Attach separate sheet if
necessary). You must also attach copies of documentation that evidences the justification for lower wage rate, including work measurement
documentation.
DLSE 106 (11/08)
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